Claims Examiner 1

JOB TITLE:

Claims Examiner 1

DEPARTMENT:

Claims (Las Vegas)

REPORTS TO:

Brooke Reid

JOB DUTIES:

1.

Investigates, analyzes, and determines extent of plan's liability concerning medical, dental,
vision, pharmacy, and/or disability claims.
2.

Calculates benefit payments and approves payment of claims.
3.

Understanding of claims processing guidelines, benefit structure, system procedures, and
miscellaneous guidelines.
4.

Calculate benefits and approve payment of claims.
5.

Refer questionable claims to team lead.
6.

Ability to work in Zenith's ETK system or comparable system by creating, updating, and
resolving logs.
7.

Identify potential problems/trends in processes to be escalated for management review.
8.

Identify potential problems and possible solutions for process improvement.
9.

Create, update, and resolve logs in Zenith American's Encounter Tracking Systems or
comparable system or its counterpart.
10.

Must meet the department quality and production standards for this job, as
provided on the work standards grid.

JOB REQUIREMENTS:

Minimum Education & Experience


* High School diploma or GED


* Healthcare background/previous experience preferred

Mental/Visual Concentration or Manual Dexterity


* Requires normal concentration


* Easily learned, simple movements

Computer Operations


* Must be PC literate


* Working knowledge of HCFA, CPT, ICD-9, HCPCS, and other medical coding protocols


* Data entry and 10-key skills required


* Proficient in claims systems

Physical Work Environment


* Normal degree of physical effort in typical office environment with comfortable, constant temperatures and absence of objectionable elements


* May be subject to interruptions


* May be required to lift a maximum of 25 lbs


* Must be able to have flexible work schedule when workflow requires


* Meets established attendance and punctuality guidelines

COMPETENCIES:

Customer Focus


* Understands customer needs, both internal and external, and looks for opportunities to provide the highest quality service

Quality Focus


* Maintains appropriate documentation


* Works with other employees/departments to ensure timely and quality service


* Must meet the departments quality and production standards for this job

Analysis


* Average analytical/problem solving skills


* Average research skills


* Mathematical proficiency required

Planning


* Solid organizational skills


* Ability to prioritize and multi-task

Communication


* Solid written, verbal, and presentation skills


* Listens actively


* Communicates effectively with participants, co-workers, and vendors

Interpersonal Relations


* Assists participants, co-workers, and vendors in a friendly, courteous, and professional manner


* Uses courtesy in communication and working with others


* Works with other employees/departments to ensure timely and quality service


* Patience and rapport w...